Provider Demographics
NPI:1437179702
Name:BRANDENBURG, KATHLEEN MILLER
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MILLER
Last Name:BRANDENBURG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY KATHLEEN
Other - Middle Name:
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6388 MAZELLE TRL SW
Mailing Address - Street 2:
Mailing Address - City:OCEAN ISLE BEACH
Mailing Address - State:NC
Mailing Address - Zip Code:28469-5777
Mailing Address - Country:US
Mailing Address - Phone:910-520-5127
Mailing Address - Fax:
Practice Address - Street 1:601 E PORTERSVILLE RD
Practice Address - Street 2:
Practice Address - City:PORTERSVILLE
Practice Address - State:PA
Practice Address - Zip Code:16051-2119
Practice Address - Country:US
Practice Address - Phone:724-601-3474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP007684363LF0000X
NC5012514363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
PASP007684OtherLICENSE